TAX INVOICE
Fee:$160.00
(GST not applicable) / / CITY OF HOBART
16 Elizabeth Street, Hobart
(03) 6238 2190


ABN 39 055 343 428
PUBLIC HEALTH RISK ACTIVITY APPLICATION FORM
(PREMISES REGISTRATION)
Public Health Act 1997 Sections 105 & 110

( * denotes mandatory field)

Applicant’sDetails

*Applicant’s Name:
ACN(ifa Company):
*Address: / Postcode:
Telephone: / *Mobile Phone:
Facsimile: / Email:

BusinessDetails

*Business Name:
*Name as on the Street Frontage of Premises:
*Premises Location Address:
*Postal Address:
Postcode:
Telephone:
Facsimile: / Email:
Emergency Contact: / Mobile Phone:
Public Health Risk Activities Proposed to be Conducted in These Premises:
*I,

(Print Full Name)

  • have read the information pre-printed on this application; and
  • have inserted and completed any and all information required on this application; and
  • have amended any and all incorrect pre-printed information on this application; and
  • declare that all information on this application, both pre-printed and inserted by me, is true, accurate and complete; and
  • acknowledge this application is not valid and assessment of the application will not commence until all application fees are paid in full; and
  • acknowledge and agree that if an email address is provided on this application I consent pursuant to Section 6 of the Electronic Transactions Act 2000 to the Council using that email address as a method of contact and for the provision of information by the Council.

*Signature of Applicant: / *Date:

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PAYMENT BY PHONE / PAYMENT IN PERSON / PAYMENT BY MAIL
Credit card payment can be made via phone by calling (03)62382190.
Upon payment please email your completed application form to: / Payment can be made in person at the Customer Service Centre, 16 Elizabeth Street, Hobart.
Business hours are 8.15am – 5.15pm Monday - Friday.
Eftpos and credit card facilities are available. / Cheques or money orders should be made payable to Hobart City Council. Post-dated cheques will not be accepted.
Mail payment together with application form to:
The General Manager
Hobart City Council
GPO Box 503, Hobart, TAS, 7001

Please submit your completed application form at the time of making payment.

Personal Information Protection Act 2004

The personal information requested on this form is personal information for the purposes of the Personal Information Protection Act 2004 (“the Act”) and will be managed in accordance with the Act.

The personal information is being collected by the Hobart City Council (“the Council”) for the purposes of managing, assessing, advising on and determining the relevant application in accordance with the Public Health Act 1997 and other related purposes. The personal information may also be used for the purpose of data collection.

The intended recipients of the personal information are Council officers, agents of the Council and/or data service providers and contractors engaged by the Council from time to time.

The supply of this information is voluntary. However, if you cannot provide, or do not wish to provide, the information sought, the Council will be unable to accept and/or process your application.

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